In a perfect world, all submitted claims would be processed correctly the first time. In the world of medical billing, however, we know this is not always the case. Even after cautiously submitting a claim it may get denied. Handling claim denials can be a frustrating, time-consuming, and complicated process.
Knowing some basic strategies for resolving claims denials can save providers time and improve practice collection. Some basic pointers for effectively handling claim denials are outlined below.
Effectively Handling Claim Denials Pointers:
Review EOBs Carefully
It may sound obvious, but it’s one of the most important steps in claims processing. When you receive remittance advice, an explanation of benefits (EOB) from a payer, review it carefully. Explanation of benefits would clearly indicate whether the claim was paid in full, delayed, partially paid, or denied.
If the claim is partially paid or if payment is denied, the remittance advice/ explanation of benefits would specify the denial reason(s) and outline the specific procedures and documentation required to resubmit the claim or file an appeal. If you feel the provided information is not clear, call the insurance rep for more information.
Appeal the Denial
If your claim got denied, you may appeal the decision as per the payer’s guidelines. Make sure your team knows the exact denial reason and its resolution. Keep in mind that appeal procedures may vary by payer and state in which you are practicing.
Your appeal should include an explanation of your reconsideration request; supporting documentation, such as a copy of the claim in question, and copies of earlier communication with the payer about the denial.
In case of claim denial due to ‘medical necessity,’ then submit additional information to demonstrate necessity. You may need to resubmit the claim or file an appeal more than once to reverse the denial decision, but don’t give up. Your persistence can demonstrate that you are serious about resolving the problem and receiving reimbursements.
Know Appeal Process
You submit an appeal, make sure you are familiar with billing guidelines and payer reimbursement policies. When you know payer policies, you are in a better position to respond. Keep current information regarding the claims adjudication and appeal processes for each payer to whom you submit claims.
Payers often include this information on their websites and, if applicable, provide hard copies of the information each time you sign a new contract with them. It is also important to submit and resubmit claims in a timely manner, within the timeframe specified by the payer or the applicable laws in your state.
Otherwise, the claim may be adjudicated based only on the information you already provided, or any requests for reconsideration or appeal may be denied as untimely.
Record Appeal Communications
When you call an insurance rep for more information about a claim, keep a record of the information you received, along with the full name of the representative with whom you spoke.
Record this information with other key information about the claim, including why the claim was partially paid, delayed, or denied; the actions your office took to follow up on the claim; and the outcome.
These records can play an important role in future actions, such as taking your appeal to higher levels, submitting complaints to the state insurance commissioner, and/or pursuing subsequent litigation.
The records can also serve as a helpful file of sample appeals letters and documentation that can aid your office in avoiding or resolving future claims denials.
Take Help from Experts
While handling claims denials can be a frustrating process, it can save you time and money in the long run by taking help from billing experts. You can effectively handle claim denials by outsourcing your medical billing to Medical Billers and Coders (MBC).
By outsourcing, you can ensure that your billing procedures are consistent with the payer’s reimbursement policies. This may able to reduce the occurrence of rejections and denials in the future.
To know more about our denial management and resolution services, email us at: info@medicalbillersandcoders.com or call us at: 888-357-3226
FAQs:
1. What should I do first when a claim is denied?
Start by carefully reviewing the Explanation of Benefits (EOB) to understand the denial reason and any required actions for resubmission or appeal.
2. How do I appeal a claim denial?
Follow the payer’s specific guidelines for appeals, providing a clear explanation, supporting documentation, and any additional information that addresses the denial reason.
3. Why is it important to know the appeal process?
Familiarity with billing guidelines and payer policies enhances your ability to respond effectively, ensuring timely submission and reducing the risk of untimely denial.
4. How should I document communications regarding claim denials?
Keep detailed records of all communications with insurance representatives, including names, dates, denial reasons, and follow-up actions taken for future reference.
5. When should I consider outsourcing billing services?
If handling claim denials becomes overwhelming, outsourcing to medical billing experts can improve your processes and reduce the occurrence of future denials.
